Patients with end-stage renal disease (ESRD) suffer from high morbidity and mortality, despite utilizing a large share of healthcare resources. It is important that efforts to contain the cost of ESRD care preserve the quality of care delivered. Due to the federal government's role as the primary payer for ESRD services, policies enacted by the Centers for Medicare and Medicaid Services have a great influence on the care of patients with ESRD. A prior emphasis on low-cost dialysis has contributed to more than a decade of consolidation in the dialysis provider market, leading to a reduction in market competition among dialysis providers from 2000 to 2010. It is unknown how competition among dialysis providers affects healthcare delivery, access to care, and health outcomes in patients on dialysis. This K23 proposal outlines a series of analyses of patients in the U.S. receiving dialysis: 1) to examine how past decreases in competition due to consolidation in dialysis provider markets has affected patient-oriented health outcomes and access to care among sicker patients; 2) to examine the role of provider market competition on quality of care, patient-oriented health outcomes, and access to care in the setting of strong financial disincentives to provide higher-cost care following enactment of the ESRD prospective payment system (PPS) or payment bundle; and 3) to examine, through direct patient interviews and standardized questionnaires, how provider and market characteristics influence patients' satisfaction with their dialysis care and choice of dialysis provider; Dr. Kevin F. Erickson is a board certified nephrologist with a background in clinical nephrology, health services research, and health economics. As a joint fellow at Stanford in Nephrology and Primary Care and Outcomes Research, Dr. Erickson has worked with a multidisciplinary team of health economists and clinical investigators to begin studying economic issues important to the care of patients with kidney disease. This career development proposal builds upon this prior experience with continued mentoring and dedicated coursework in industrial organization economics, econometrics, qualitative research, survey and clinical trial design. The proposed study has the potential to improve health outcomes in patients with kidney disease. Additionally, by supporting planned career development activities, this K23 award will provide Dr. Erickson with critically important, advanced didactic and experiential training as he develops his career as an independent physician-scientist studying how economic incentives influence - and can be used to improve - health outcomes in patients with kidney disease.